Long-term Challenges for ARV Programmes on the African Continent: Experience From Southern Africa

1Médecins sans frontières (MSF) South Africa, Head of Mission, Cape Town, South Africa, 2Department of Public Health and Family Medicine, University of Cape Town, 3MSF South Africa

Key issues:

The first projects to routinely offer free ART in resource-constrained settings have now been in operation for 5 years. We describe trends and outcomes after 5 years of treatment provision in one such programme in Khayelitsha, South Africa, while drawing lessons from similar MSF experiences in the Southern African Region.

Meeting challenges::

Prospective cohort study of all treatment-naïve adults started on ART until the end of 2005 in Khayelitsha and observational studies in other programmes.

Results:

In an analysis of > 2000 adults started on ART by the end of 2005, 76% of patients remain in care at 48 months, of whom 84% remain on their first-line regimen. Median baseline CD4 at initiation rose from 46 in 2001 to 105 in 2005, and correspondingly, mortality by 6 months fell in parallel from 13% to 5% (two-thirds of losses occurred in first six months). The proportion of patients attaining viral loads < 400 copies/ml at 6 months has remained stable between annual cohorts at between 88% and 91%. Long-term drug toxicity, mainly due to D4t (16.7% cumulatively by 36 months on stavudine compared to 8.3% on zidovudine), has necessitated the introduction of specific monitoring tools and will require an alternative first-line regimen in the middle term. At 48 months, 17 % of patients are on second-line, while there is no patient-friendly, affordable second-line regimen available for the time being. While total consultations have multiplied by more than 7 in the first 48 months to comply with scale up targets, they will still need to be multiplied by another factor 4 to reach universal coverage targets by 2010: this has major impact on the quality of care (loss to follow-up has increased to 4% at 12 months for the most recent annual cohort) and needs for decentralisation/ simplification. This can only be realised while applying a nurse-based strategy in an international context of nurses emigration due to poaching by Western countries.

Conclusion (max 400 words):

ARV treatment at a large-scale is feasible and can be successful, but universal coverage will only be attainable if: new drugs and diagnostic tools are available, urgent measures are taken to limit health staff emigration, programmes are further simplified and approaches standardised.